28492 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. /1 /1 q ^/N
BUILDING DIVI PPLICATION/PERMIT PLUMBING.-MECHANICAL L}V( 4 J4 L
BUILDING PROJECT IDENTIFICATION
BUILqtLASANITARY NO, APPLICATION SUBMITTAL DAI
Ho
/YJ S Te qtD � 60683 1 A" ,
OWNERS NAME. l' YIIONr CONTRACTOR'S NAME: LIC NO'.
A N S S NIC CONTROL M
• ARCHITECT/ENGINEER: LICNO: ADDRESS: ❑
Si GN, BUN Cae94—
CONTACT: PHONE: BUILDING PERMIT INFO
_ ❑ Consultant Fees Paid by Applicant(Initial) BLDG E ECf PLUMB MECH
LICENSEDCONTRACuOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
El
1 nereny affirm,laid[;all fm,Bu under Businessland
Prenna ons Cede. 9(enndneneng JOB DESCRIPTION
F��d'Z i flit un]d if DivisionJof the Business and Professions Code.endm license is
� in full R-cand if y en PERFIIT ISSUANCE RESIDENTIAL
QF.Ul- License Class y_Lic.4 �SFDWL ❑KITCHEN REMODEL.
NGeAPPLIANCES-RSIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
z ++ C . SDECLAI(AIOtT PANELS ❑MULT-UNIT EISTRUCfURAL
zo.
I maholu al my plans shall be used as Public records MODIFICATION
O Z 4 UP P0 200 AMPS
1-•4F"W Licensed Professional ❑INTERIOR 11 CHIMNEY REPAIR
,1 201-IMAMN IMPROVEMENT
a � OWNER-BUILDER DECLARATION OVER 1000 AMPS
I hereFy off rte that I um exenmt from the Convucmr's Licenxe Law for the [I BATH REMODEL/REPAIR ❑DEMOLITION
LiyS d U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W LL O F. which requires a pcmJt as construct.alma improve,demolish,or repair any stmcmrc
fpp"�ys prior to its ismance,also requires the applicant for such Parrik in Glc a signedstatement SPECIAL CIRCUIT/MISC.
z�y that he is licensed pursuant to the provisions of the Comrdemes License Law(Chapter 9
5u1�n�0 (commencing with Section]0(ad of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
6 c that he is exempt merchant and the basis for the alleged exemption,Any violation of
applicant fora ❑NEW BLDGIADIJITION El DEMOLITION
Section]031.5 by any
t o than Gve hundmd dollars($SW)hit subject the applicant Penalty of POWER DEVICES OTENANT ❑FOODSERVICE
F G O 1,as owner of the properly,or my ensployas with wages as theirsele compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
SaF will do the work.and the shuttle is no 'mended or fcrcd fnr.wle(ticcJ(W4,Bu<ine.v QOTHER
a 3 m and Profcsaions C e:The Commcm Lids docs not apply m an owner of OfI11FTS-SWITCHES-FIXTURES
properly who buil or imp v an s such work himself or through �— T
his own c" toy pct i d e t m p •to• t. not intended or offered for NEW RESIDENTIAL ELECTR SQ PC
su,
e.lf.hate hu go peen tis.wldwthnone ycansfcomPldion.the SQ.FT FLOOR AREA $/SQ.PT.
owner-builder will a the burden of pmvmg that he did not build or improve for put-
w.,
ut- VtA,COND.
AAA (Ca -
pnseofa.w c /♦e
❑ 1,as nw r of th ropcmy,am exclusively conicactif¢,ayp-1I��I sed c.=cmrs mT L.
construct the project(Sec. Buttttyyy� essinna W9c'onvac A Li- ^�
cemseLawdoes net apply
y hobuildsor.mpras.theron,told QTY. MEIN ERMIT FEE C/'/ ��
wnc
who mmmet[or such Pmje s idt8c 1 enscd pursuanuo the Contractors
License Law. E V�L�yL. 1g9S
El I am eaempt under Sec. ,B&P C for this reason
IN T-WATF,R(IiA)
• Owner pate -a VALUATION
WORndetSnOMofNrju c)n DECLARATIOg TF. E IhercbyaRrmunderPenehyofpcjuryoneofthefollowin Jedarations: R. EA tA,COND. STORIES TYPECONSTAUC1lf
sotto..as provided fill by Section 3700 of the Labor Cae,forthe pccfamwrme of thework for which this permit is issued. R TRAP
• I have and will maintain Worker's Compensation Insurance,as required by Section
IoRhe Labm Cudr,fnrthe performanecofthe work lo-which this permit is ictal. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
My Worke Corn natation nsumlt ecarrier amt Policy
Carver Policy No: er art' v GAS-EA.SYSTEM-OVER 4(EA)
CF,RI'IFICA ;OFF,%F,MF'TIONIROM RKt.'
COMPENSATION INSURANCE GREASEIINDUSTRI.WASTE INTERCEPTOR
lws) l
(This section need not be completed ifthe Pcnnit is(orahundred dollen 18100) OREASETRAP BUILDING IVT IS
orPLANCHECK FEE
Loy any that in o the perforany
ofthe bacoork or which this Perdre W rkersaComp all SEWER-SANITARY-STORM EA.200 FT.
sa employ any utfor in any runner co¢s m become subject m the Workers Compnn- ENERGY FEE
z Applicant
of Califnmia.Data
� O A licant WATER HIiATER W/VENT/ELECTR
.Z �. PF GRADING FEE
y NOTICE bj APPLICANT:If,after making this Cevions o of Labor io d you should WATER SYSTEM/IREAUNG
become suhjttun the Worker's h Im Compensation ennit ions of the labor Cale,you must SOILS FEE
forthwith comply wish such provisions ur this permit shall MJcemcJ revoked. WATER SERVICE
a �
U CONSTRUCTION LENDING
gimbal ENC, NEW RESIDENTIAL PLMB, SQ.FT PAID
V kArreby which his there isacormtmai097,Cing agency for the perfnrmm�ce of D Receipt#
Hthe work Nam this permit is issued(Sec.309],Civ.C.)
O V Lender's Name TOTAL:
Lcnder'I Addles '2� - TOTAL:
�" Z) 1 crnethat I haveittrite that application o stem that the above information is BUILDING BE
N n
I �1
L) Zcoed I egrete m comply with all city and countyy ordinances and sum laws renting In QTy, MECHANICAL PERMIT FEE
, buildingconstmetiomund hisethonze aprcsematives of this city mercer ur<m the SEISMIC FEE
Mwm
ae- entioned properly far minspection purposes.
(We)-9.m,licemdemnify and keep hmmlessthe City of Cupertino against PERMIT ISSUANCE ELECTRIC E
Iiabilidesjudgmems,cost and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in coreespence of the granting of this Pscaut.
PLUMBING E
APPLICANT O 4TIONS NUS AND WILL COMPLY WITH///LL ryryry'OOON POINT AIR HANDLING UNIT(TO lo,000 CFM)
SOURCE L'GUJ.n4T1�0 aN,5. ,x ��� / MECHANIC LFEE
C .Jq/-/'l ofd. / AIR HANDLING UNIT(OVER IO.IX%)CPM) CONSTRUCONTAX
Stgnattere u Apphcem/ omractur Date EKHAUST HOOD(WMUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATI FEE
Will the applicant or future building occupant same or handle haamdous material HEAPING UNIT TO 100,000 BTU)
as defined by the Cupcnino Municipal Cale.Chapter 9.12,and the Health and Safety
Cods Section 25532(ap HEATING UNIT(OVER 100,0110 BTU) \
E3 Yes XNo
VEKI'IWTION FAN(SINGLE RESID) PAID
Will the applicant orinantra building occupant use equipment l devices which Dam Receipt
Diamerzardous air contaminants as depnW by the Bay Area Air Quality Management BOILER-COMP(3HP OR 1W,Ofq BT'U)
Uixaia, TO L:
Fl Yet ROLLER-COMP(OVER I MOOD BTU)
I have read the frocanusnuanals requirementsunder Chapter 695 of the Cali- AIR CONDITIONER
main Health&Safcry Cale,Sections 25505,25533 and 25534.1 uMermand that if the ISSUANCE DATE
builiingdoesnotcu mly hareamnanI'Bratit is my msPonsibilitymnaifytM occupant NEW RESIDENTIAL MECH, SQ.IT
of Ne aqui t ' INR poor m issuance of a Ccnir,."of f cupanc
Owner/or...aul rAoge �y—
TOTAL: ISSUED BY:
OFFICE